New Patient Paperwork

Today's Date

First name

Last name

Date of Birth

Month

Day

Year

Phone

Address:

How did you hear about us?

Referred by:

The information in this questionnaire is strictly confidential.

By answering these questions, you have enabled the paramedical esthetician to give you the best treatment for your particular skin type.

How would you like your skin to look and why?

How quickly do you want to clear and/or get results?

How much work are you willing to put in or would you like to rely on us?

Describe your current skincare routine: (AM & PM)

Are you currently under the care of a dermatologist?

Yes

If yes, please list current medications:

Are you interested in before/after photos to track progress?

Yes

Stress Level

Skin Type

Salt Intake

Caffeine intake

Do you smoke?

Are you on hormonal birth control?

Are you pregnant or breastfeeding?

How many 8oz glasses of water do you drink daily?

Have you ever had an allergic reaction to a product?

If yes, please list products or ingredients:

Is there anything else you would like us to know?

Appointments:

All virtual appointments are scheduled in advance. Our email is checked regularly, and we will make every effort to accommodate you as promptly as possible. To help us stay on schedule, please ensure you're ready at the scheduled time. For any questions or changes, feel free to contact us at info@cslaskincare.com.

I confirm that I have read the above informed consents:

I declare that the information I’ve provided is accurate & complete.

New Patient Paperwork

Contact Us

Address

Facial Clinic Partners